1. Starting From Scratch: Common Pediatric Dermatoses Richard J. Antaya, M.D. Associate Professor, Dermatology & Pediatrics Yale University School of Medicine

2. IMPETIGO CONTAGIOSA Both Staph aureus and Strep pyogenes Humid climates and summer months Secondary to trauma and insect bites Treatment –Oral - cephalexin. dicloxacillin, amoxicillin- clavulanate, erythromycin, cefaclor –Topical - mupirocin (Bactroban), retapamulin oint 1% (Altabax), soak off crusts

3. Bullous Impetigo Always Staph aureus Epidermolytic toxin cleaves stratum granulosum Phage group II Same toxin as Staph Scalded Skin Syndrome Rx: Oral anti-Staph antibiotics

4. Lyme Disease multi-stage, multi-system disease agent:Borrelia burgdorferi, vector: Ixodes ticks late spring to mid fall Erythema Migrans (previouslyECM) in 80% –expanding, erythematous, round or oval areas –solitary or multiple, concentric rings –variable induration, pain, pruritus untreated cases - arthritis, neurologic, cardiac, ophthalmic complications

5. Lyme Disease Treatment young children – amoxicillin older children/adults - doxycycline

6. Tinea Corporis Pearls Fungal infection of the superficial epidermis KOH wet prep for diagnosis –Scrape with edge of glass slide; not scalpel –Apply one drop Chlorazol Black E fungal stain –Place coverslip –Scan on low power with condenser at lowest point “If it’s scaly…scrape it!” Don’t get CLIAphobia

7. Tinea Corporis Treatment Pearls Topical azole* unless widespread Treat b.i.d. for 2 to 4 weeks Terbinafine, naftifine, butenafine, ciclopirox –Fungicidal –$econd line Look for source * clotrimazole, ketoconazole, miconazole, econazole

8. Granuloma Annulare Small, firm papules form annular plaque Skin-colored, dusky to violaceous No scale (- epidermal, + dermal inflammation) Acral locations Necrobiosis (destruction) of dermal collagen Subcutaneous - deep nodules Periosteal – “bony” hard; over scalp, tibia No treatment, no associations, reassurance

9. TINEA CAPITIS Dermatophyte infection of the hair shaft Presentation –hair loss and/or multiple “black dots” –patchy areas of scale –lymphadenopathy Common in African-American children Usually caused by Trichophyton tonsurans (does not fluoresce)

11. TINEA CAPITIS Oral griseofulvin 20-25 mg/kg/day in a single dose with fatty food Treat for 6 - 12 weeks Adjunctive use of selenium sulfide (Selsun Blue), ketoconazole, or ciclopirox shampoo may decrease fungal shedding

12. TINEA CAPITIS Alt ernative Therapies Terbinafine (Lamisil) 5-8 mg/kg/d, 4-6 wk –Oral granules FDA approved Itraconazole (Sporonox) – 5-6 mg/kg/d –Liquid contains cyclodextrin diarrhea, pancreatic adenomas in rats Fluconazole (Diflucan) – 6 mg/kg/d –no more effective than griseofulvin* Br J Dermatol 1996;135:86-88 AAD poster New Orleans, LA 2005*

13. KERION Boggy, highly inflammatory reaction Bacteria may be cultured (Staph) Treatment Griseofulvin Prednisone (1-2mg/kg/day) for ~5 days +/- Oral antibiotics

14. Id Reaction Distinguish from Drug hypersensitivity Urticaria Edematous, erythematous papules Lineup along hairline, postauricular, Atopic dermatitis distribution

15. TINEA VERSICOLOR Malassezia furfur(Pityrosporum orbiculare) More common in adolescents and adults Treatment Overnight selenium sulfide solution/ shampoo (1% OTC and 2.5% Rx) Ketoconazole 400 mg P.O. in a single dose, may repeat in one week

16. SCABIES DIAGNOSIS 1. Hx of intractable itching 2. Hx of possible exposure 3. Character and distribution of lesions 4. Microscopic exam of skin scrappings

17. SCABIES In Older Children Distribution anterior axillary lines inner aspect of upper arms areolae penis wrists and interdigital webs ankles

18. SCABIES Infants Diffuse eczematous dermatitis Frequently involves entire cutaneous surface (face, palms, soles) Inflammatory nodular lesions of axillae / diaper area of very young Burrows, papules, vesicles and pustules

19. SCABIES TREATMENT 5% permethrin cream (Elimite) –Total body in infants and older children –Don’t recommend neck to toes –8-14 hour (overnight); repeat in 7 days Ivermectin (Stromectol) –2 nd line, 200 mcg/kg, repeat 1 week Wash clothing / bedding >120 o F next a.m. Treat all close contacts Treat the “patient” –Moderate potency topical steroids

20. Louse: 6-legged, wingless, translucent, 2-3 mm

21. Head Lice Myths vs Facts Don’t affect only “dirty” individuals Not linked to poor hygiene or living conditions Don’t jump or fly Location of nit varies with temperature and humidity (1/4 – 6 inches)

22. Pediculosis Capitis Head Lice Symptoms –nocturnal pruritus –red macules on nape of neck and scalp Don’t spread any other disease, rare impetigo, malaise Transmission: head-to-head contact

23. Head Lice Diagnosis Combing vs Visual inspection –4x more effective –2x faster Combing hair with nit comb –Teeth spacing 0.2-0.3 mm –Wet hair may be more effective Procedure –Routine comb or brush –Insert louse comb at crown –Gently touches scalp –Draw firmly down, angle distally –Comb systematically at least twice –Examine comb after each pass –Usually 1 minute to find first louse Nurses out-perform MDs Mumcuoglu KY et al. Pediatr Dermatol 2001;18:9-12 Head lice/nit combs

24. Pediculosis Capitis First-line Treatment FDA-approved OTC –0.3% pyrethrins (RID), permethrin 1% (Nix) –Apply to scalp 10 min and rinse –Repeat 8-10 days –Apply 1:1 vinegar:H 2 0, enzyme solution to enhance combing –Comb with metal nit comb Re-examination for live lice (nurse preferably) after another 8-10 days Cost ~$20 for 1-2 treatments Adapted from Guidelines for the Treatment of Resistant Pediculosis; 6/14/99

25. Pediculosis Capitis Second Line Treatment If live lice present after 2 OTC treatments malathion lotion 0.5% (Ovide®) Side effects: scalp irritation, dandruff, conjunctivitis, flammable until dries 7 days after the treatment 90% were lice free Application –To dry hair-thoroughly wet hair and scalp –Allow to dry uncovered –Shampoo hair after 20 min – 8 hr, nit combing –Only repeat in 7-9 days if lice still present Supplied 2 oz bottles (1 application = $206) Adapted from Guidelines for the Treatment of Resistant Pediculosis; 6/14/99

26. 5% Benzyl Alcohol Lotion Ulesfia NEW FDA approved April 2009 Kills head lice by asphyxiation w/o potential neurotoxic SE > 6 months of age 2 PC studies for FDA approval – 628 pts –Two 10-minute treatments, 1 week apart –14 days after the treatment 75% were lice free –SE - irritation of the skin, scalp, and eyes, application site numbness –Avoid in premature infants - serious respiratory, heart- or brain- related adverse events Now available

27. Ulesfia Lotion Usage Guidelines Hair Length Short –0-2 inches –2-4 inches Medium –4-8 inches –8-16 inches Long –16-22 inches –> 22 inches Amount of Ulesfia Lotion/ Tx –4-6 oz (½-¾ bottle) –6-8 oz (¾-1 bottle) –8-12 oz (1-1½ bottles) –12-24 oz (1½-3 bottles) –24-32 oz (3-4 bottles) –32-48 oz (4-6 bottles) $41.59/8oz bottle Girl w/ long hair 3 bottles x 2 =$249.54

28. Pediculosis Capitis Third-line Treatments Oral Bactrim –Gram neg bacteria in lice GI tract –10 day course p.o. (dose for A.O.M) Nuvo lotion* Cetaphil Cleanser ® –Apply to scalp, dry with hair dryer –Rinse out next day, repeat qwk x 3 –Nit removal unnecessary –96% cure –Suffocate the lice with hair drier Ivermectin –P.O.- 200 mcg/kg x 1 on days 1 and 10 –0.8% topical solution/shampoo * Pearlman, D. L. Pediatrics 2004;114:e275-e279 Copyright ©2004 American Academy of Pediatrics untreated louse (Speare et al) Nuvo-treated louse coated with dried-on lotion

29. School Exclusion In 1998, 50% of US school nurses would not allow a child with nits back into school Infestation present weeks before detection 75% with nits alone are not infested School exclusion not recommended by American Public Health Association “No nit” policy is questionable ($367 million/yr lost)

30. WARTS Human papilloma virus (HPV) Verrucae vulgaris, plana, plantaris, and condyloma acuminata Highest incidence in 10-19 y/o 25% disappear in 3-6 months 65% disappear in 2 years

31. WART THERAPY Topical salicylic acid in collodion hs with paring Cryotherapy with liquid nitrogen Duct tape – apply for 6.5 days/week Heat therapy Pulsed Dye Laser * Aldara (imiquimod 5% cream) Immunotherapy (SADBE, skin test antigens) Oral cimetidine x 2-3 months still controversial * Adapted from Tan OT, Lasers in Surg and Medicine,1993, 13:127-37

32. Molluscum Contagiosum Poxvirus infection of the epidermis Mistaken for varicella or vesicles Infectious (pools, fomites)… but benign Inflamed, itchy, infected Untreated lasts 2-48 months (avg 18 mo) STD in adolescents and adults Severe in HIV infected patients

33. Molluscum Contagiosum Treatment Tincture of time Office-based therapy (q 2 weeks) –Cantharidin (Blister beetle juice) application –Liquid nitrogen cryotherapy –Curettage –Lacerate or lance with needle –Candida Antigen intralesional injection Home treatments –Tretinoin (Retin-A) 0.025% gel with Q-tip qhs –Imiquimod 5% cream (Aldara) q.d. to b.i.d.

34. ALLERGIC CONTACT DERMATITIS Acute lesions - erythema, vesiculation, oozing Chronic lesions - dry and lichenified Most common offenders  Toxicodendrons - Poison ivy, oak, sumac (~80%)  Metals (Ni) (10-15%)  Neomycin  Preservatives and fragrances  Shoes (chromates and rubber)  Black henna tatoos (ppd)

35. Prominent Pruritic Periumbilical Papules: Allergic Contact Dermatitis (ACD) to Nickel 38 children with suspected ACD to nickel prominent subumbilical and periumbilical papules generalized, lichenoid papular dermatitis resembling an id reaction patch testing performed in 9 (24%) all 9 (100%) patients had positive patch test results for nickel, confirming the diagnosis Adapted from Sharma V. Pediatric Dermatology. 19(2):106-9, 2002 Mar-Apr.

36. Cellphone Contact Dermatitis with Nickel Allergy Tested numerous brands of cell phones Most common sites with nickel –menu buttons –decorative logos on the headsets –metallic frames around the LCD screens Berkovitch L, Luo J. CMAJ 2008;178(1):23-4.

37. Results of nickel spot testing of 23 wireless communication devices CELLPHONE BlackBerry 8700c Speakerphone (back of phone) BlackBerry Pearl None Kyocera KX444 None LG Verizon VX8300 None Motorola L2 Headset (decorative logo) Motorola Razr Headset (decorative logo) Motorola SLVR Headset (decorative logo) Motorola Q Headset (decorative logo) Motorola i580 None Motorola i870 None Nokia 6061 None Nokia 6062 None Nokia 6820 None Nokia 6230 None Nokia 6682 None Palm Treo 650 None Samsung e105 Metal around the screen, menu button Samsung d807 Menu button Sony Ericsson W600i Menu button Sony Ericsson W810i Menu button Sony Ericsson T610 Handset (if paint is chipped) Sony Z520a None BLUETOOTH HEADSET Plantronics Explorer 320 None Berkovitch L, Luo J. CMAJ 2008;178(1):23-4.

38. Dimethylglyoxime Positive test for Ni + Metal jean clasps 10% Belt buckles 53% Byer TT. Periumbilical allergic contact dermatitis: blue jeans or belt buckles?. Pediatric Dermatology. 21(3):223-6, 2004 May-Jun.

39. Dimethylglyoxime Nickel Test Kit Allertest Ni Allerderm PO Box 2070 Petaluma CA 94953 $12.50 + $6 S&H www.nickelallergy.com 800-365-6868

40. CONTACT DERMATITIS TREATMENT Topical steroids - moderate potency 2 week course of oral prednisone if widespread/facial May last for 1 to 3 weeks after exposure Identify allergen and avoid

41. PORT-WINE STAINS Capillary Malformation Will not involute, does not proliferate/spread May darken and thicken May become nodular w/ age May become significant, lifelong cosmetic and psychosocial problem Laser may be effective

42. Yale Vascular Anomalies Clinic (VAC) Infantile hemangiomas Other vascular neoplasms Capillary malformations Lymphatic and other malformations Other vascular lesions – PG, angiokeratomas

43. Capillary Malformation“ Port Wine Stain” Pulsed Dye Laser Treatment response rate –variable –65% - 75% complete to considerable response –multiple treatments (5-20 average) –child versus adult –improved response anatomical site - forehead, lateral face, temple geographic recurrences can occur

44. SUN PROTECTION STATISTICS skin cancer - most common malignancy in U.S.skin cancer - most common malignancy in U.S. 1 million new skin cancers diagnosed in 19971 million new skin cancers diagnosed in 1997 about 7,300 skin cancer deaths in 1996about 7,300 skin cancer deaths in 1996 malignant melanoma in U.S.malignant melanoma in U.S. –1973 - cases 5.7 /100,000; mortality of 1.6/100,000 –1994 - cases 12.5/100,000; mortality of 2.2/100,000 –41,600 new cases diagnosed in 1998 sun is the cause of at least 90% of all skin cancerssun is the cause of at least 90% of all skin cancers

45. SUN PROTECTION BCC / SCC associated with cumulative exposureBCC / SCC associated with cumulative exposure melanoma associated with short, intense exposure, possibly UVAmelanoma associated with short, intense exposure, possibly UVA blistering sunburns in childhood more than double the risk of melanomablistering sunburns in childhood more than double the risk of melanoma significant amount of lifetime sun exposure occurs before age 18significant amount of lifetime sun exposure occurs before age 18 anticipatory guidance early is essentialanticipatory guidance early is essential

46. Good Sun Sense broad-rimmed hats tightly woven clothing sunscreens SPF 15 or more (> 6mo) sun Guard by Rit ® in wash (UPF 5  30) UV protective sunglasses nature shade, limit midday exposure avoid tanning beds!

47. Evaluating Hair Loss in Children Localized or Diffuse Congenital or Acquired

48. Acquired & Localized Hair Loss 1.Alopecia areata 2.Trauma –Trichotillomania / Hair pulling –Traction alopecia 3.Tinea capitis

49. Alopecia Areata

50. Alopecia Areata HISTORY Worse prognosis associated with disease present > 1 year or young age at onset positive family history of AA or atopy extensive involvement – especially ophiasis pattern or alopecia totalis Down syndrome

51. Angular/geometric shapes or borders Linear lesions Incomplete loss Perifollicular petechiae and excoriations No scale TRICHOTILLOMANIA Hairs of varying length Broken / twisted hairs

52. Hair Pulling “Splitting Hairs” 1.Acute hair pulling associated with stress 2.Trichotillomania (OCD) 3.Hair pulling associated with other psychiatric disorders

53. Traction Alopecia Hair thinning in particular areas Very few fractured hairs Hair shafts smaller in diameter Hair care / style R/O child abuse RX: education, discontinue trauma Follicular papules

54. Pilomatricoma Calcifying Epithelioma of Malherebe Benign adnexal tumor from hair cortex Rock-hard, bluish, “tent sign” 2 mm -1 cm nodule Face > extremities 10% of all skin nodules/tumors in childhood Most asymptomatic, inflammation in some Spontaneous regression not reported Surgical excision, recurrence < 5% Familial 13.3% occurrences* Multiple 26.7% –Rubinstein-Taybi, Turner, Gardner syndromes * Adapted from Pediatric Dermatology. 14(6):430-2, 1997 Nov-Dec.